Application For An Initial Medicare Provider/ Registration Number For An Allied Health Professional Page 2

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7
Applicant’s details
Are these contact details for this application only, or for general
mailout purposes?
This application only
1
Dr
Mr
Mrs
Miss
Ms
Other
General mailout purposes
Family name
Qualifications
First given name
8
What is your allied health profession?
You must complete a separate form for each profession.
Other given name(s)
Tick one only
Aboriginal and Torres Strait
2
Islander Health Practitioner
Mental Health Nurse
Date of birth
Aboriginal Health Worker
Occupational Therapist
/
/
Audiologist
Osteopath
3
Your sex
Chiropodist
Physiotherapist
Male
Female
Chiropractor
Podiatrist
4
Languages spoken (other than English)
Diabetes Educator
Psychologist
Dietitian
Social Worker
Exercise Physiologist
Speech Pathologist
Contact details
9
Professional qualification
5
Practice name or building
10
Place obtained
Property or department
11
Year obtained
Unit
Suite
Shop
Floor number
Street number
Registration/membership details
You must have current registration for any state or
Street name
territory in which the required practice location is situated or
provide evidence of eligibility in accordance with the eligibility
requirements that can be found in the Health Insurance (Allied
Suburb
Health Services) Determination available at comlaw.gov.au
Eligibility requirements can be found at
humanservices.gov.au/healthprofessionals or by calling
State
Postcode
www.
132 150.
6
Practice phone number
12
Registration/membership details
(
)
State or territory of registration/membership
Mobile number
Registration/membership number
Fax number
(
)
Date registered
Email
/
/
Registration/membership number
@
Pager number
2 of 3
HW063.1503 (formerly 1449)

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